=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124816764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE BLUMENTHAL MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2025
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 PLEASANT ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-229-3985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 FAIRVIEW AVE
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03275-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-706-3918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------